P - 44438Building PLUMBING Permit No.: �C� "Z;(C-�
Inspections COMMERCIAL APPLICATION Received By:�
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX ���; ' �^ � � � �p
EFFECTIVE 1-1-2010
DATE � Z� [[� YOUR E-MAIL ADDRESS I i m
SITEADDRESS ,3(�(' (`�r„���,-�_ ���.�
TENANT SUITE NO.
PROPERTY NAME:
OWNER/ ADDRESS: CITY STATE ZIP
TENANT
PHONE:
CONTRACTOR NAME: t.�. (pi i1
SUBMIT A COPY OF STATE LICENSE # EXP DATE IZ �.3/ ^/�
YOURSTATE ^
LICENSE, BOND AND PLUMBING BOND # �I3 S L s( 9 i c°� XP DATE
CERTIFICATE OF ADDRESS: Z i/ ����ti�� d,,� (%•r /�IG.�CITY ' STAT ZIP ..�U �Cd
INSURANCE pHONE %3 — FAX � SCi /�—�
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PERMIT TYPE ��STITUTIONAL r O MULTI-FAMILY ❑ SWIMMING POOL
O TOWNHOUSE COMMERCIAL/INDUSTRIAL � OTHER
TYPE OF WORK: � NEW ❑ REPLACEMENT �ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK D�,c� �`� — S l � ,' (L
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_CLOTHES WASHER `FLOORDRAINS `RPZ VALVE URINAL
_ DISHWASHER ' GAS PIPING BACKFLOW PREV. � WATER HEATER
_ DRINKING FOUNTAIN _ GREASE TRAP `ROOF DRAINS i WATER METER
_ FAUCET ` KITCHEN SINK _ SHOWER _ WATER PIPING
_ FLAMMABLE WASTE TANK LAUNDRY TRAY _ SLOP SINK _ WATER SOFTENER
Z. LAVATQRY _ SWIMMING POOL � WATER CLOSET
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Total Job $ O All fees are based on valuation, including the cost of labor and materials.
Valuation
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Permit Fee $ �� (1.25% of Job Valuation / Minimum fee: $35)
Surcharge $•�U Valuation X.0005 or Minimum .50
Total Due $�� �(� 6 Make Checks Payable to: City of Fridley
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID IJNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case o 11 k which requires review and approval of plans.
SIGNATURE OF APPLICAN • P�NAME: J C/'T ��/�J DATE: u 2 !
APPROVAL INSPECTOR SIGNATURE� DATE�
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, Citv of ridlev Buildin� Ins�ections De�artment
6431 University Avenue NE, Fridley,lVlN 55432
763-572-3604 FAX: 763-502-4977